Medical Decision-Making the only Component for 2021 Office and Ambulatory Services

In January 2021, the billing guidelines changed for office and outpatient-based ambulatory services.

During my interview with the C-suite occupants for my physician advisor job, I had this epiphany that the hospital gets paid, too. For those of you who do facility billing, you may not be aware that the provider gets paid as well. There are CPT® codes called evaluation and management, or E&M, codes.

Historically, most E&M levels of service (LOS) were either based on components – some combination of history, physical examination, and medical decision-making – or on time, half of which had to be spent in counseling and/or coordination of care. Each component had specific requirements, such as that an extended history must have four elements or the status of at least three chronic conditions; or that a comprehensive physical examination must hit a certain number of bullet points or body systems.

Generally speaking, new patients had to meet three out of three components, and established patients had to meet two out of three components, to satisfy the billing requisites. It isn’t that difficult to meet Level 5 criteria for history and physicals. However, sometimes people forget that the most important condition is that there must be medical necessity for the service. A patient with a hangnail doesn’t warrant a Level 5 E&M service, regardless of how many review-of-system points you hit, or whether you do a complete physical exam. Therefore, I always believed that the complexity of medical decision-making should be one of the components factored into selecting the LOS.

In January 2021, the billing guidelines changed for office and outpatient-based ambulatory services, and I believe this has been for the better (2021 E&M Guidelines for Office or Other Outpatient Services). Even if you work exclusively in inpatient services, you should pay attention to this, because it is likely that the changes will be expanded over other places of care and E&M services in the future.

There are now two different ways to assign an E&M LOS for office or outpatient professional services: based on complexity of medical decision-making or total time. The CPT code set is designed and maintained by a panel authorized by the American Medical Association (AMA), so physicians were integrally involved in the revision. Let’s deconstruct these a bit.

The options for level of medical decision-making are straightforward, corresponding to 99202 or 99212, i.e., Level 2, low (Level 3), moderate (Level 4), and high (Level 5). There is a very detailed table of what constitutes each of these levels included in the guidelines (see link above). There are three columns: number and complexity of problems addressed, data reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management.

I have an engagement where I am assisting a physician practice to generate appropriate documentation and ensure that their coders/billers compliantly assign accurate LOS. I am going to share a few tips I have gleaned with you:

  • The problems must be documented as having been “addressed” at the encounter. This really means MEAT (monitor, evaluate, assess, treat), or the Erica Remer version, MEATIeR. The provider must give some indication that they are monitoring, evaluating, assessing, and treating, or that the condition is impactful and r

The clinician should document specific details. If every condition is “stable,” then that is probably insufficient. However, “hypertension – BPs are normotensive and stable” reflects this patient. It does not need to be a dissertation; it just needs enough details to help you or a colleague take care of the patient, and for a payor to determine that you have done so.

  • Generic templated documentation without any expansion or addition is not sufficient. Why are you having the patient weigh themselves daily, and what action should they take, under what circumstances? Obviously, you want the patient to be compliant with their medications. What is it about the specific medicine that has caused you to add that to the assessment and plan (e.g., “compliance with anticoagulation urged to prevent recurrent DVT”)?
  • The reason the provider gets paid the big bucks is for their analysis of data. “Echo” is not enough. “Patient informed that echo demonstrated slight improvement of ejection fraction from 35 to 40 percent, still consistent with chronic systolic heart failure” shows that the provider has interpreted the test and discussed the findings with the patient.
  • I recommend that each provider make an acronym expansion of “diagnosis and/or treatment significantly limited by social determinants of health (SDoH), such as…” and insert “SDoH conditions applicable.” SDoH is a Level 4 risk factor.

It is interesting, when I discuss with providers their documentation deficiencies and they report what they were thinking that elicited a cryptic notation, their explanation is usually concise, clear, and exactly what they should be documenting. I recommend that they add that to the record we are considering, and be that explicit on future charts.

In this practice, providers will explain their thought processes to the coders, who then assign the LOS accordingly. I cautioned them that the support needs to be added to the record. An auditor is not going to replicate the chart-by-chart discussion that the practice has set in place. You know the old adage: if it isn’t documented…

Practitioners don’t have to write a thesis. They just need to tell the coders what they are thinking and why they are doing what they are doing for each patient. In other words, what was the medical decision they made?

Programming Note: Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 a.m. Eastern.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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